Barbara is a 25-year-old, heterosexual, Caucasian female and is the mother of a 6-month-old baby boy. She is currently unemployed and has neither specific skills nor a college education. At the time we first met, she was living her with her son, Jonah, and her boyfriend, Scott (also Jonah’s father), in a home that her grandparents purchased for her. Scott, a 29-year-old, heterosexual, Caucasian male, is employed by a flooring company, although his work is not regular. Both Barbara and Scott have a long history of severe polysubstance abuse, including heroin addiction. They are both currently prescribed methadone.
Jonah was born with severe birth defects due in part to Barbara’s and Scott’s drug use. Jonah remained in the hospital for several weeks after his birth, and during that time he underwent multiple surgeries. Among other abnormalities, he was born with two stomachs, one of which formed on the exterior of his body. He will need additional surgeries in the future and his stomach will never be fully functioning. The full extent of his disabilities is not certain at this time.
When our sessions began, Barbara was experiencing financial problems and was trying to obtain Social Security Disability for Jonah. Because Jonah is unable to attend day care due to his fragile health, Barbara has had to stay home and has reported feelings of isolation.
Due to the child’s condition at birth, the hospital staff had reported the family to the Department of Social Services to ensure that the parents would provide appropriate care for him and that the child would be safe in the home environment. After initial contact was established with the parents, a number of concerns were noted, and the family was recommended for additional case management services. Among the concerns were the parents’ denial about the extent of their substance abuse and its negative effects on their lives and their child’s life.
Financial issues were a problem, and family support was limited only to Jonah’s maternal great-grandparents, who are elderly and not in good health. Scott’s parents had divorced when he was very young, and he had no relationship with his father, who also had substance abuse issues. Barbara’s parents divorced when she was very young, and she was raised primarily by her grandparents. She reported that her father was and remains an alcoholic. She presented as anxious and depressed and experiencing low self-esteem. She appeared to be bonded with her child and took very good care of him, although she clearly struggled with his health issues. She also struggled with her responsibility for his disabilities. She tried hard to educate herself about his health problems and learn how to parent in general.
Initially, both parents were uncooperative and resistant to participate in the case management process. Scott felt that because he was going to a clinic every day for his methadone, he no longer had a substance abuse problem. I pointed out to him that this was a stopgap measure and he could not spend his life on methadone. I also pointed out that he needed greater insight into his problems in order to overcome them. He never really engaged in the process and frequently did not attend our scheduled appointments, saying he had to work. Barbara stated that he often was not really working and that he was still using drugs. Barbara seemed to feel that she did not really have a problem because she was not using street drugs, but was receiving her medications from a pain management clinic as the result of a motorcycle accident several years ago. As subsequent home visits were made, Barbara began disclosing her feelings to me and addressing some of her issues.
All of my clients are involuntarily in the system, so I frequently utilize Carl Rogers’ person-centered approach because it seems to be the most effective method to establish rapport and ultimately achieve change. Having empathy for your client, encouraging them, and providing support is critical to facilitating change.
Barbara and I made a list of the major issues that she needed and wanted to address and then prioritized them. We did some research to help her find possible solutions to her needs. Barbara was actively involved in the process and, over time, began to feel less overwhelmed. I encouraged her to begin individual therapy sessions, and she agreed to participate. I made the referral, and Barbara found a therapist with whom she really connected. She also began to disclose to me that there were other problems in her relationship with Scott, including incidents of domestic violence and a pattern of verbal abuse designed to affect her self-esteem. We engaged in a frank discussion with her grandparents, and they agreed to let her and Jonah come to live with them so that they would both be removed from any threat of harm and so that Barbara’s anxiety level could be reduced while she continued in therapy. One evening, Scott came to the grandparents’ home and was high and extremely intoxicated. He assaulted Barbara and her grandfather and was subsequently arrested. She obtained a restraining order and was committed to terminating contact with Scott due to his unwillingness to acknowledge his problems and make any positive changes. She continued with therapy and enrolled in the community college to obtain skills that would allow her to care for herself and child.